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Section II General Surgery P203Surgical Recall Sixth > Trauma, C38 P226-246 > Flashcards

Trauma, C38 P226-246 Flashcards

1
Q

What widely accepted
protocol does trauma care
in the United States follow?
P226

A

Advanced Trauma Life Support (ATLS)
precepts of the American College of
Surgeons

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2
Q

What are the three main
elements of the ATLS
protocol?
P226

A
  1. Primary survey/resuscitation
  2. Secondary survey
  3. Definitive care
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3
Q

How and when should the
patient history be obtained?
P227

A

It should be obtained while completing
the primary survey; often the rescue
squad, witnesses, and family members
must be relied upon

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4
Q

PRIMARY SURVE
What are the five steps of
the primary survey?
P227

A 
Think: “ABCDEs”:
Airway (and C-spine stabilization)
Breathing
Circulation
Disability
Exposure and Environment
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5
Q 
PRIMARY SURVE
What principles are followed
in completing the primary
survey?
P227
A

Life-threatening problems discovered
during the primary survey are always
addressed before proceeding to the
next step

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6
Q

AIRWAY
What are the goals during
assessment of the airway?
P227

A

Securing the airway and protecting the

spinal cord

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7
Q 
AIRWAY
In addition to the airway,
what MUST be considered
during the airway step?
P227
A

Spinal immobilization

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8
Q

AIRWAY
What comprises spinal
immobilization?
P227

A

Use of a full backboard and rigid cervical

collar

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9
Q 
AIRWAY
In an alert patient, what is
the quickest test for an
adequate airway?
P227
A

Ask a question: If the patient can speak,

the airway is intact

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10
Q

AIRWAY
What is the first maneuver
used to establish an airway?
P227

A

Chin lift, jaw thrust, or both; if successful,
often an oral or nasal airway can be
used to temporarily maintain the airway

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11
Q 
AIRWAY
If these methods are
unsuccessful, what is the
next maneuver used to
establish an airway?
P227
A

Endotracheal intubation

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12
Q 
AIRWAY
If all other methods are
unsuccessful, what is the
definitive airway?
P228 (picture)
A 
Cricothyroidotomy, a.k.a. “surgical airway”:
Incise the cricothyroid membrane
between the cricoid cartilage inferiorly
and the thyroid cartilage superiorly and
place an endotracheal or tracheostomy
tube into the trachea
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13
Q 
AIRWAY
What must always be kept
in mind during difficult
attempts to establish an
airway?
P228
A 
Spinal immobilization and adequate
oxygenation; if at all possible, patients
must be adequately ventilated with 100%
oxygen using a bag and mask before any
attempt to establish an airway
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14
Q

BREATHING
What are the goals in
assessing breathing?
P228

A

Securing oxygenation and ventilation

Treating life-threatening thoracic injuries

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15
Q

BREATHING
What comprises adequate
assessment of breathing?
P228

A 
Inspection—for air movement, respiratory
    rate, cyanosis, tracheal shift, jugular
    venous distention, asymmetric chest
    expansion, use of accessory muscles
    of respiration, open chest wounds
Auscultation—for breath sounds
Percussion—for hyperresonance or
    dullness over either lung field
Palpation—for presence of subcutaneous
    emphysema, flail segments
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16
Q 
BREATHING
What are the life-threatening
conditions that MUST be
diagnosed and treated
during the breathing step?
P228
A

Tension pneumothorax, open

pneumothorax, massive hemothorax

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17
Q

BREATHING
What is it?
P229

A

Injury to the lung, resulting in release of air
into the pleural space between the normally
apposed parietal and visceral pleura

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18
Q

BREATHING
How is it diagnosed?
P229

A

Tension pneumothorax is a clinical
diagnosis: dyspnea, jugular venous
distention, tachypnea, anxiety, pleuritic
chest pain, unilateral decreased or absent
breath sounds, tracheal shift away from
the affected side, hyperresonance on the
affected side

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19
Q

BREATHING
What is the treatment of a
tension pneumothorax?
P229

A 
Rapid thoracostomy incision or immediate
decompression by needle thoracostomy
in the second intercostal space
midclavicular line, followed by tube
thoracostomy placed in the anterior/
midaxillary line in the fourth intercostal
space (level of the nipple in men)
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20
Q

BREATHING
What is the medical term for
a “sucking chest wound”?
P229

A

Open pneumothorax

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21
Q

BREATHING
What is a tube thoracostomy?
P229

A

“Chest tube”

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22
Q 
BREATHING
How is an open
pneumothorax diagnosed
and treated?
P229
A 
Diagnosis: usually obvious, with air
    movement through a chest wall defect
    and pneumothorax on CXR
Treatment in the ER: tube thoracostomy
    (chest tube), occlusive dressing over
    chest wall defect
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23
Q

BREATHING
What does a pneumothorax
look like on chest X-ray?
P229 (picture

A

Loss of lung markings (Figure shows a
right-sided pneumothorax; arrows point
out edge of lung-air interface)

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24
Q

Flail Chest
What is it?
P230 (picture)

A

Two separate fractures in three or more

consecutive ribs

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25
Q

Flail Chest
How is it diagnosed?
P230

A

Flail segment of chest wall that moves
paradoxically (sucks in with inspiration
and pushes out with expiration opposite
the rest of the chest wall)

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26
Q 
Flail Chest
What is the major cause of
respiratory compromise with
flail chest?
P230
A

Underlying pulmonary contusion!

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27
Q

Flail Chest
What is the treatment?
P230

A

Intubation with positive pressure
ventilation and PEEP PRN (let ribs heal
on their own)

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28
Q

Cardiac Tamponade
What is it?
P230

A

Bleeding into the pericardial sac, resulting
in constriction of heart, decreasing inflow
and resulting in decreased cardiac output
(the pericardium does not stretch!)

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29
Q

Cardiac Tamponade
What are the signs and
symptoms?
P230

A

Tachycardia/shock with Beck’s triad,

pulsus paradoxus, Kussmaul’s sign

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30
Q

Cardiac Tamponade
Define the following:
Beck’s triad
P231

A
  1. Hypotension
  2. Muffled heart sounds
  3. JVD
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31
Q

Cardiac Tamponade
Define the following:
Kussmaul’s sign
P231

A

JVD with inspiration

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32
Q

Cardiac Tamponade
How is cardiac tamponade
diagnosed?
P231

A

Ultrasound (echocardiogram)

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33
Q

Cardiac Tamponade
What is the treatment?
P231

A

Pericardial window—if blood returns
then median sternotomy to rule out and
treat cardiac injury

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34
Q

Massive Hemothorax
How is it diagnosed?
P231

A

Unilaterally decreased or absent breath
sounds; dullness to percussion; CXR, CT
scan, chest tube output

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35
Q

Massive Hemothorax
What is the treatment?
P231

A

Volume replacement
Tube thoracostomy (chest tube)
Removal of the blood (which will allow
apposition of the parietal and visceral
pleura, sealing the defect and slowing
the bleeding)

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36
Q 
Massive Hemothorax
What are indications for
emergent thoracotomy for
hemothorax?
P231
A 
Massive hemothorax 
1. >1500 cc of blood on initial
placement of chest tube
2. Persistent >200 cc of bleeding via
chest tube per hour x 4 hours
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37
Q

CIRCULATION
What are the goals in
assessing circulation?
P231

A

Securing adequate tissue perfusion;

treatment of external bleeding

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38
Q

CIRCULATION
What is the initial test for
adequate circulation?
P231

A

Palpation of pulses: As a rough guide,
if a radial pulse is palpable, then systolic
pressure is at least 80 mm Hg; if a
femoral or carotid pulse is palpable, then
systolic pressure is at least 60 mm Hg

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39
Q

CIRCULATION
What comprises adequate
assessment of circulation?
P231

A

Heart rate, blood pressure, peripheral
perfusion, urinary output, mental status,
capillary refill (normal <2 seconds), exam
of skin: cold, clammy = hypovolemia

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40
Q

CIRCULATION
Who can be hypovolemic
with normal blood pressure?
P232

A

Young patients; autonomic tone can
maintain blood pressure until
cardiovascular collapse is imminent

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41
Q 
CIRCULATION
Which patients may not
mount a tachycardic
response to hypovolemic
shock?
P232
A

Those with concomitant spinal cord
injuries
Those on -blockers
Well-conditioned athletes

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42
Q

CIRCULATION
How are sites of external
bleeding treated?
P232

A

By direct pressure; / tourniquets

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43
Q 
CIRCULATION
What is the best and
preferred intravenous (IV)
access in the trauma
patient?
P232
A

“Two large-bore IVs” (14–16 gauge),
IV catheters in the upper extremities
(peripheral IV access)

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44
Q

CIRCULATION
What are alternate sites of
IV access?
P232

A

Percutaneous and cutdown catheters in
the lower leg saphenous; central access
into femoral, jugular, subclavian veins

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45
Q 
CIRCULATION
For a femoral vein catheter,
how can the anatomy of the
right groin be remembered?
P232
A 
Lateral to medial “NAVEL”:
    Nerve
    Artery
    Vein
    Empty space
    Lymphatics
Thus, the vein is medial to the femoral
    artery pulse (Or, think: “venous close
    to penis”)
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46
Q

CIRCULATION
What is the trauma
resuscitation fluid of choice?
P232

A

Lactated Ringer’s (LR) solution
(isotonic, and the lactate helps buffer the
hypovolemia-induced metabolic acidosis)

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47
Q

CIRCULATION
What types of decompression
do trauma patients receive?
P232

A

Gastric decompression with an NG tube
and Foley catheter bladder decompression
after normal rectal exam

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48
Q 
CIRCULATION
What are the
contraindications to
placement of a Foley?
P232
A 
Signs of urethral injury:
Severe pelvic fracture in men
Blood at the urethral meatus (penile
    opening)
“High-riding” “ballotable” prostate
    (loss of urethral tethering)
Scrotal/perineal injury/ecchymosis
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49
Q 
CIRCULATION
What test should be
obtained prior to placing a
Foley catheter if urethral
injury is suspected?
P233
A

Retrograde UrethroGram (RUG): dye in
penis retrograde to the bladder and x-ray
looking for extravasation of dye

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50
Q 
CIRCULATION
How is gastric
decompression achieved
with a maxillofacial
fracture?
P233
A

Not with an NG tube because the tube
may perforate through the cribriform
plate into the brain; place an oral-gastric
tube (OGT), not an NG tube

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51
Q

DISABILITY
What are the goals in
assessing disability?
P233

A

Determination of neurologic injury

Think: neurologic disability

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52
Q

DISABILITY
What comprises adequate
assessment of disability?
P233

A 
Mental status—Glasgow Coma Scale
    (GCS)
Pupils—a blown pupil suggests ipsilateral
    brain mass (blood) as herniation of the
    brain compresses CN III
Motor/sensory—screening exam for
    lateralizing extremity movement,
    sensory deficits
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53
Q

DISABILITY
Describe the GCS scoring
system.
P233

A 
Eye opening (E)
4—Opens spontaneously
3—Opens to voice (command)
2—Opens to painful stimulus
1—Does not open eyes
(Think: Eyes = “four eyes”)
Motor response (M)
6—Obeys commands
5—Localizes painful stimulus
4—Withdraws from pain
3—Decorticate posture
2—Decerebrate posture
1—No movement
(Think: Motor = “6-cylinder motor”)
Verbal response (V)
5—Appropriate and oriented
4—Confused
3—Inappropriate words
2—Incomprehensible sounds
1—No sounds
(Think: Verbal = “Jackson 5”)
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54
Q

DISABILITY
What is a normal human GCS?
P234

A

GCS 15

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55
Q

DISABILITY
What is the GCS score for a
dead man?
P234

A

GCS 3

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56
Q

DISABILITY
What is the GCS score for a
patient in a “coma”?
P234

A

GCS ⩽8

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57
Q

DISABILITY
How does scoring differ if
the patient is intubated?
P234

A

Verbal evaluation is omitted and replaced
with a “T”; thus, the highest score for an
intubated patient is 11 T

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58
Q

EXPOSURE AND ENVIRONMENT
What are the goals in
obtaining adequate exposure?
P234

A

Complete disrobing to allow a thorough
visual inspection and digital palpation of
the patient during the secondary survey

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59
Q

EXPOSURE AND ENVIRONMENT
What is the “environment”
of the E in ABCDEs?
P234

A

Keep a warm Environment (i.e., keep the
patient warm; a hypothermic patient can
become coagulopathic)

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60
Q 
SECONDARY SURVEY
What principle is followed
in completing the secondary
survey?
P234
A

Complete physical exam, including all
orifices: ears, nose, mouth, vagina,
rectum

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61
Q

SECONDARY SURVEY
Why look in the ears?
P234

A

Hemotympanum is a sign of basilar skull
fracture; otorrhea is a sign of basilar skull
fracture

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62
Q 
SECONDARY SURVEY
Examination of what part of
the trauma patient’s body is
often forgotten?
P234
A

Patient’s back (logroll the patient and

examine!)

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63
Q

SECONDARY SURVEY
What are typical signs of
basilar skull fracture?
P234

A

Raccoon eyes, Battle’s sign, clear otorrhea

or rhinorrhea, hemotympanum

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64
Q 
SECONDARY SURVEY
What diagnosis in the
anterior chamber must
not be missed on the eye exam?
P234
A

Traumatic hyphema = blood in the

anterior chamber of the eye

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65
Q 
SECONDARY SURVEY
What potentially destructive
lesion must not be missed on
the nasal exam?
P235
A

Nasal septal hematoma: Hematoma must
be evacuated; if not, it can result in
pressure necrosis of the septum!

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66
Q

SECONDARY SURVEY
What is the best indication
of a mandibular fracture?
P235

A

Dental malocclusion: Tell the patient to
“bite down” and ask, “Does that feel
normal to you?”

67
Q 
SECONDARY SURVEY
What signs of thoracic
trauma are often found on
the neck exam?
P235
A

Crepitus or subcutaneous emphysema from
tracheobronchial disruption/PTX; tracheal
deviation from tension pneumothorax;
jugular venous distention from cardiac
tamponade; carotid bruit heard with
seatbelt neck injury resulting in carotid
artery injury

68
Q

SECONDARY SURVEY
What is the best physical exam
for broken ribs or sternum?
P235

A

Lateral and anterior-posterior compression

of the thorax to elicit pain/instability

69
Q 
SECONDARY SURVEY
What physical signs are
diagnostic for thoracic great
vessel injury?
P235
A 
None: Diagnosis of great vessel injury
requires a high index of suspicion based
on the mechanism of injury, associated
injuries, and CXR/radiographic findings
(e.g., widened mediastinum)
70
Q 
SECONDARY SURVEY
What is the best way to
diagnose or rule out aortic
injury?
P235
A

CT angiogram

71
Q 
SECONDARY SURVEY
What must be considered in
every penetrating injury of
the thorax at or below the
level of the nipple?
P235
A

Concomitant injury to the abdomen:
Remember, the diaphragm extends to the
level of the nipples in the male on full
expiration

72
Q

SECONDARY SURVEY
What is the significance of
subcutaneous air?
P235

A

Indicates PTX, until proven otherwise

73
Q 
SECONDARY SURVEY
What is the physical exam
technique for examining the
thoracic and lumbar spine?
P235
A

Logrolling the patient to allow complete
visualization of the back and palpation
of the spine to elicit pain over fractures,
step off (spine deformity)

74
Q 
SECONDARY SURVEY
What conditions must exist
to pronounce an abdominal
physical exam negative?
P235
A

Alert patient without any evidence of
head/spinal cord injury or drug/EtOH
intoxication (even then, the abdominal
exam is not 100% accurate)

75
Q 
SECONDARY SURVEY
What physical signs may
indicate intra-abdominal
injury?
P236
A

Tenderness; guarding; peritoneal signs;
progressive distention (always use a
gastric tube for decompression of air);
seatbelt sign

76
Q

SECONDARY SURVEY
What is the seatbelt sign?
P236

A

Ecchymosis on lower abdomen from
wearing a seatbelt (10% of patients with
this sign have a small bowel perforation!)

77
Q

SECONDARY SURVEY
What must be documented
from the rectal exam?
P236

A

Sphincter tone (as an indication of spinal
cord function); presence of blood (as an
indication of colon or rectal injury); prostate
position (as an indication of urethral injury)

78
Q 
SECONDARY SURVEY
What is the best physical
exam technique to test for
pelvic fractures?
P236
A

Lateral compression of the iliac crests
and greater trochanters and anteriorposterior
compression of the symphysis
pubis to elicit pain/instability

79
Q

SECONDARY SURVEY
What is the “halo” sign?
P236

A

Cerebrospinal fluid from nose/ear will form

a clear “halo” around the blood on a cloth

80
Q 
SECONDARY SURVEY
What physical signs indicate
possible urethral injury, thus
contraindicating placement
of a Foley catheter?
P236
A

High-riding ballotable prostate on
rectal exam; presence of blood at the
meatus; scrotal or perineal ecchymosis

81
Q

SECONDARY SURVEY
What must be documented
from the extremity exam?
P236

A

Any fractures or joint injuries; any open
wounds; motor and sensory exam,
particularly distal to any fractures; distal
pulses; peripheral perfusion

82
Q 
SECONDARY SURVEY
What complication after
prolonged ischemia to the
lower extremity must be
treated immediately?
P236
A

Compartment syndrome

83
Q

SECONDARY SURVEY
What is the treatment for
this condition?
P236

A

Fasciotomy (four compartments below

the knee)

84
Q 
SECONDARY SURVEY
What injuries must be
suspected in a trauma
patient with a progressive
decline in mental status?
P236
A 
Epidural hematoma, subdural hematoma,
    brain swelling with rising intracranial
    pressure
But hypoxia/hypotension must be
    ruled out!
85
Q

TRAUMA STUDIES
What are the classic blunt
trauma ER x-rays?
P237

A
  1. AP (anterior-to-posterior) chest film

2. AP pelvis film

86
Q

TRAUMA STUDIES
What are the common
trauma labs?
P237

A

Blood for complete blood count,
chemistries, amylase, liver function tests,
lactic acid, coagulation studies, and type
and crossmatch; urine for urinalysis

87
Q 
TRAUMA STUDIES
Will the hematocrit be
low after an acute massive
hemorrhage?
P237
A

No (no time to equilibrate)

88
Q

TRAUMA STUDIES
How can a C-spine be
evaluated?
P237

A
  1. Clinically by physical exam

2. Radiographically

89
Q 
TRAUMA STUDIES
What patients can have
their C-spines cleared by a
physical exam?
P237
A

No neck pain on palpation with full range
of motion (FROM) with no neurologic
injury (GCS 15), no EtOH/drugs, no
distracting injury, no pain meds

90
Q

TRAUMA STUDIES
How do you rule out a
C-spine bony fracture?
P237

A

With a CT scan of the C-spine

91
Q 
TRAUMA STUDIES
What do you do if no bony
C-spine fracture is apparent
on CT scan and you cannot
obtain an MRI in a
COMATOSE patient?
P237
A

This is controversial; the easiest answer is

to leave the patient in a cervical collar

92
Q 
TRAUMA STUDIES
Which x-rays are used for
evaluation of cervical spine
LIGAMENTOUS injury?
P237
A

MRI, lateral flexion and extension

C-spine films

93
Q 
TRAUMA STUDIES
What findings on chest film
are suggestive of thoracic
aortic injury?
P237
A 
Widened mediastinum (most common
finding), apical pleural capping, loss
of aortic contour/KNOB/AP window,
depression of left main stem bronchus,
nasogastric tube/tracheal deviation,
pleural fluid, elevation of right mainstem
bronchus, clinical suspicion, high-speed
mechanism
94
Q

TRAUMA STUDIES
What study is used to rule
out thoracic aortic injury?
P238

A

Spiral CT scan of mediastinum looking
for mediastinal hematoma with CTA
Thoracic arch aortogram (gold standard)

95
Q 
TRAUMA STUDIES
What is the most common
site of thoracic aortic
traumatic tear?
P238
A

Just distal to the take-off of the left

subclavian artery

96
Q 
TRAUMA STUDIES
What studies are available to
evaluate for intra-abdominal
injury?
P238
A

FAST, CT scan, DPL

97
Q

TRAUMA STUDIES
What is a FAST exam?
P238

A

Ultrasound: Focused Assessment with

Sonography for Trauma = FAST

98
Q

TRAUMA STUDIES
What does the FAST exam
look for?
P238

A

Blood in the peritoneal cavity looking at
Morison’s pouch, bladder, spleen, and
pericardial sac

99
Q

TRAUMA STUDIES
What does DPL stand for?
P238

A

Diagnostic Peritoneal Lavage

100
Q 
TRAUMA STUDIES
What diagnostic test is the
test of choice for evaluation
of the unstable patient with
blunt abdominal trauma?
P238
A

FAST

101
Q 
TRAUMA STUDIES
What is the indication for
abdominal CT scan in blunt
trauma?
P238
A

Normal vital signs with abdominal

pain/tenderness/mechanism

102
Q 
TRAUMA STUDIES
What is the indication for
DPL or FAST in blunt
trauma?
P238
A

Unstable vital signs (hypotension)

103
Q

TRAUMA STUDIES
How is a DPL performed?
P238

A

Place a catheter below the umbilicus (in
patients without a pelvic fracture) into
the peritoneal cavity
Aspirate for blood and if <10 cc are
aspirated, infuse 1 L of saline or LR
Drain the fluid (by gravity) and analyze

104
Q

TRAUMA STUDIES
What is a “grossly positive” DPL?
P238

A

⩾10 cc blood aspirated

105
Q 
TRAUMA STUDIES
Where should the DPL
catheter be placed in a
patient with a pelvic
fracture?
P239
A 
Above the umbilicus
Common error: If you go below the
    umbilicus, you may get into a pelvic
    hematoma tracking between the fascia
    layers and thus obtain a false-positive
    DPL
106
Q

TRAUMA STUDIES
What constitutes a positive
peritoneal tap?
P239

A

Prior to starting a peritoneal lavage, the DPL catheter should be aspirated; if >10 mL of blood or any enteric contents are aspirated, then this constitutes a positive tap and requires laparotomy

107
Q 
TRAUMA STUDIES
What are the indicators of a
positive peritoneal lavage in
blunt trauma?
P239
A 
Classic:
   Inability to read newsprint through
      lavaged fluid
   RBC ⩾100,000/mm
   WBC ⩾500/mm (Note: mm, not
      mm)
   Lavage fluid (LR/NS) drained from
      chest tube, Foley, NG tube
Less common:
   Bile present
   Bacteria present
   Feces present
   Vegetable matter present
   Elevated amylase level
108
Q

TRAUMA STUDIES
What must be in place
before a DPL is performed?
P239

A

NG tube and Foley catheter (to remove
the stomach and bladder from the line
of fire!)

109
Q

TRAUMA STUDIES
What injuries does CT scan miss?
P239

A

Small bowel injuries and diaphragm

injuries

110
Q

TRAUMA STUDIES
What injuries does DPL
miss?
P239

A

Retroperitoneal injuries

111
Q 
TRAUMA STUDIES
What study is used to
evaluate the urethra in cases
of possible disruption due to
blunt trauma?
P239
A

Retrograde urethrogram (RUG)

112
Q

TRAUMA STUDIES
What are the most emergent
orthopaedic injuries?
P240

A
  1. Hip dislocation—must be reduced
    immediately
  2. Exsanguinating pelvic fracture (binder
    or external fixator)
113
Q

TRAUMA STUDIES
What findings would require
a celiotomy in a blunt trauma victim?
P240

A

Peritoneal signs, free air on CXR/CT
scan, unstable patient with positive FAST
exam or positive DPL results

114
Q

TRAUMA STUDIES
What is the treatment of a
gunshot wound to the belly?
P240

A

Exploratory laparotomy

115
Q

TRAUMA STUDIES
What is the evaluation of a
stab wound to the belly?
P240

A 
If there are peritoneal signs, heavy
bleeding, shock, perform exploratory
laparotomy; otherwise, many surgeons
either observe the asymptomatic stab
wound patient closely, use local wound
exploration to rule out fascial
penetration, or use DPL
116
Q

PENETRATING NECK INJURIES
What depth of neck injury
must be further evaluated?
P240

A

Penetrating injury through the platysma

117
Q

PENETRATING NECK INJURIES
Define the anatomy of the neck by trauma zones:
Zone III
P240

A

Angle of the mandible and up

118
Q

PENETRATING NECK INJURIES
Define the anatomy of the neck by trauma zones:
Zone II
P240

A

Angle of the mandible to the cricoid

cartilage

119
Q

PENETRATING NECK INJURIES
Define the anatomy of the neck by trauma zones:
Zone I
P240 (picture)

A

Below the cricoid cartilage

120
Q 
PENETRATING NECK INJURIES
How do most surgeons treat
penetrating neck injuries
(those that penetrate the
platysma) by neck zone:
Zone III
P241
A

Selective exploration

121
Q 
PENETRATING NECK INJURIES
How do most surgeons treat
penetrating neck injuries
(those that penetrate the
platysma) by neck zone:
Zone II
P241
A

Surgical exploration vs. selective

exploration

122
Q 
PENETRATING NECK INJURIES
How do most surgeons treat
penetrating neck injuries
(those that penetrate the
platysma) by neck zone:
Zone I
P241
A

Selective exploration

123
Q

PENETRATING NECK INJURIES
What is selective
exploration?
P241

A

Selective exploration is based on diagnostic
studies that include A-gram or CT A-gram,
bronchoscopy, esophagoscopy

124
Q 
PENETRATING NECK INJURIES
What are the indications for
surgical exploration in all
penetrating neck wounds
(Zones I, II, III)?
P241
A 
“Hard signs” of significant neck damage:
shock, exsanguinating hemorrhage,
expanding hematoma, pulsatile
hematoma, neurologic injury, subQ
emphysema
125
Q 
PENETRATING NECK INJURIES
How can you remember the
order of the neck trauma
zones and Le Forte fractures?
P241 (picture)
A

In the direction of carotid blood flow

126
Q

MISCELLANEOUS TRAUMA FACTS
What is the “3-for-1” rule?
P241

A

Trauma patient in hypovolemic shock
acutely requires 3 L of crystalloid (LR)
for every 1 L of blood loss

127
Q

MISCELLANEOUS TRAUMA FACTS
What is the minimal urine
output for an adult trauma patient?
P241

A

50 mL/hr

128
Q 
MISCELLANEOUS TRAUMA FACTS
How much blood can be lost
into the thigh with a closed
femur fracture?
P242
A

Up to 1.5 L of blood

129
Q 
MISCELLANEOUS TRAUMA FACTS
Can an adult lose enough
blood in the “closed” skull
from a brain injury to cause
hypovolemic shock?
P242
A

Absolutely not! But infants can lose
enough blood from a brain injury to
cause shock

130
Q

MISCELLANEOUS TRAUMA FACTS
Can a patient behypotensive
after an isolated head injury?
P242

A

Yes, but rule out hemorrhagic shock!

131
Q

MISCELLANEOUS TRAUMA FACTS
What is the brief ATLS history?
P242

A 
“AMPLE” history:
    Allergies
    Medications
    PMH
    Last meal (when)
    Events (of injury, etc.)
132
Q 
MISCELLANEOUS TRAUMA FACTS
In what population is a
surgical cricothyroidotomy
not recommended?
P242
A

Any patient younger than 12 years; instead

perform needle cricothyroidotomy

133
Q

MISCELLANEOUS TRAUMA FACTS
What are the signs of a
laryngeal fracture?
P242

A

Subcutaneous emphysema in neck
Altered voice
Palpable laryngeal fracture

134
Q

MISCELLANEOUS TRAUMA FACTS
What is the treatment of
rectal penetrating injury?
P242

A 
Diverting proximal colostomy; closure
of perforation (if easy, and definitely if
intraperitoneal); and presacral drainage
135
Q 
MISCELLANEOUS TRAUMA FACTS
What is the treatment of
EXTRAperitoneal minor
bladder rupture?
P242
A

“Bladder catheter” (Foley) drainage and
observation; intraperitoneal or large
bladder rupture requires operative closure

136
Q

MISCELLANEOUS TRAUMA FACTS
What intra-abdominal injury is
associated with seatbelt use?
P242

A

Small bowel injuries (L2 fracture,

pancreatic injury)

137
Q

MISCELLANEOUS TRAUMA FACTS
What is the treatment of a
pelvic fracture?
P242

A

+/- pelvic binder until the external
fixator is placed; IVF/blood; +/- A-gram
to embolize bleeding pelvic vessels

138
Q 
MISCELLANEOUS TRAUMA FACTS
Bleeding from pelvic fractures
is most commonly caused by
arterial or venous bleeding?
P242
A

Venous (≈85%)

139
Q 
MISCELLANEOUS TRAUMA FACTS
If a patient has a laceration
through an eyebrow, should
you shave the eyebrow prior
to suturing it closed?
P242
A

No—20% of the time, the eyebrow will

not grow back if shaved!

140
Q 
MISCELLANEOUS TRAUMA FACTS
What is the treatment of
extensive irreparable biliary,
duodenal, and pancreatic
head injury?
P243
A

Trauma Whipple

141
Q 
MISCELLANEOUS TRAUMA FACTS
What is the most common
intra-abdominal organ
injured with penetrating
trauma?
P243
A

Small bowel

142
Q

MISCELLANEOUS TRAUMA FACTS
How high up do the
diaphragms go?
P243

A

To the nipples (intercostal space #4);
thus, intra-abdominal injury with
penetrating injury below the nipples
must be ruled out

143
Q 
MISCELLANEOUS TRAUMA FACTS
Classic trauma question:
“If you have only one vial of
blood from a trauma victim
to send to the lab, what test
should be ordered?”
P243
A

Type and cross (for blood transfusion)

144
Q

MISCELLANEOUS TRAUMA FACTS
What is the treatment of
penetrating injury to the colon?
P243

A

If the patient is in shock, resection and
colostomy
If the patient is stable, the trend is
primary anastomosis/repair

145
Q

MISCELLANEOUS TRAUMA FACTS
What is the treatment of
small bowel injury?
P243

A

Primary closure or resection and primary

anastomosis

146
Q

MISCELLANEOUS TRAUMA FACTS
What is the treatment of
minor pancreatic injury?
P243

A

Drainage (e.g., JP drains)

147
Q 
MISCELLANEOUS TRAUMA FACTS
What is the most commonly
injured abdominal organ
with blunt trauma?
P243
A

Liver (in recent studies)

148
Q

MISCELLANEOUS TRAUMA FACTS
What is the treatment for
significant duodenal injury?
P243

A

Pyloric exclusion:

  1. Close duodenal injury
  2. Staple off pylorus
  3. Gastrojejunostomy
149
Q

MISCELLANEOUS TRAUMA FACTS
What is the treatment for
massive tail of pancreas injury?
P244

A 
Distal pancreatectomy (usually perform
splenectomy also)
150
Q

MISCELLANEOUS TRAUMA FACTS
What is “damage control” surgery?
P244

A 
Stop major hemorrhage and GI soilage
Pack and get out of the O.R. ASAP to
bring the patient to the ICU to warm,
correct coags, and resuscitate
Return patient to O.R. when stable,
warm, and not acidotic
151
Q

MISCELLANEOUS TRAUMA FACTS
What is the “lethal triad”?
P244

A 
“ACH”:
    1. Acidosis
    2. Coagulopathy
    3. Hypothermia
(Think: ACHe = Acidosis, Coagulopathy,
Hypothermia)
152
Q 
MISCELLANEOUS TRAUMA FACTS
What comprises the workup/
treatment of a stable
parasternal chest gunshot/
stab wound?
P244
A
  1. CXR
  2. FAST, chest tube, / O.R. for subxiphoid
    window; if blood returns, then
    sternotomy to assess for cardiac injury
153
Q

MISCELLANEOUS TRAUMA FACTS
What is the diagnosis with
NGT in chest on CXR?
P244 (picture)

A 
Ruptured diaphragm with stomach in
pleural cavity (go to ex lap)
154
Q 
MISCELLANEOUS TRAUMA FACTS
What films are typically
obtained to evaluate
extremity fractures?
P244
A

Complete views of the involved extremity,
including the joints above and below the
fracture

155
Q

MISCELLANEOUS TRAUMA FACTS
Outline basic workup for a victim of severe blunt trauma In ER:
Airway, physical exam. IV X 2, labs, type and cross, OGT/NGT, Foley, chest tube PRN
X-rays: CXR, pelvic, femur
(if femur fracture is suspected)

[Note: AP = anteroposterior; Ext = extremity; OGT = orogastric tube;
FAST = Focused Assessment Sonogram for Trauma; lat = lateral; C = cervical.]
P245 (Table)

A

(see table

156
Q 
MISCELLANEOUS TRAUMA FACTS
What finding on ABD/pelvic
CT scan requires ex lap in
the blunt trauma patient
with normal vital signs?
P245
A

Free air; also strongly consider in the
patient with no solid organ injury but lots
of free fluid = both to rule out hollow
viscus injury

157
Q 
MISCELLANEOUS TRAUMA FACTS
Can you rely on a negative
FAST in the unstable patient
with a pelvic fracture?
P245
A

No—perform DPL (above umbilicus)

158
Q 
MISCELLANEOUS TRAUMA FACTS
What lab tests are used to
look for intra-abdominal
injury in children?
P246
A

Liver function tests (LFTs) = ↑AST

and/or ↑ALT

159
Q

MISCELLANEOUS TRAUMA FACTS
What is the only real indication
for MAST trousers?
P246

A

Prehospitalization, pelvic fracture

160
Q

MISCELLANEOUS TRAUMA FACTS
What is the treatment for
human and dog bites?
P246

A

Leave wound open, irrigation, antibiotics

161
Q 
MISCELLANEOUS TRAUMA FACTS
What percentage of pelvic
fracture bleeding is
exclusively venous?
P246
A

85%

162
Q

MISCELLANEOUS TRAUMA FACTS
What is sympathetic
ophthalmia?
P246

A

Blindness in one eye that results in
subsequent blindness in the contralateral
eye (autoimmune)

163
Q 
MISCELLANEOUS TRAUMA FACTS
What can present after blunt
trauma with neurological
deficits and a normal brain
CT scan?
P246
A

Diffuse Axonal Injury (DAI), carotid

artery injury

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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